Ten years on from the chemotherapy underdosing bungle, survivor and advocate Andrew Knox is concerned not enough has changed to protect patients — including SA Health's incident reporting system.
at either the Royal Adelaide Hospital and Flinders Medical Centre over a six-month period in 2014 and 2015.
"In my view the Safety Learning System method of reporting adverse incidents does not work," he wrote in his published findings."The email system of communication between clinicians and other professionals in order to impart information concerning protocol changes and content is fraught with danger."
"The seriousness of the error was compounded by the fact that when it was discovered, there was no plan of action," he said. Andrew Knox with his wife on their 46th wedding anniversary while he was in hospital undergoing a stem cell transplant."It doesn't only apply to chemo, it applies to everything within the health system," he said.
But that review also found that a "patchiness in the culture of reporting" affected whether incidents would be notified. "There are clear policies and guidelines supporting safety of patients and management of incidents, which all clinicians are required to adhere to."(SA Health said all of the remaining recommendations had been addressed, including the roll-out of a new state-wide IT-based prescribing system which was due to be completed early next year.
Acute Myeloid Leukaemia Chemotherapy Bungle SA Health Royal Adelaide Hospital Flinders Medical Centre Coronial Inquest Anthony Schapel Bernadette Mulholland Relapse Cancer Incident Reporting System Clincians SA Government Safety Learning System Recommendations Cytarabine
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